June 2016

Ethics Corner

Kamal Ibrahim, MD, FRCS(C), MA
Ethics and Professionalism Committee Chair

Is this an ethical issue? The committee publishes in each issue of the newsletter a case for a possible ethical conflict and invites members to send their comments. The ethical issue case for this newsletter is the over use of Ponte osteotomy in routine AIS surgeries.

Please send your comments to The committee will collect all responses, summarize and publish them in the next newsletter.

The case:

14 years old male with 51 degrees Rt Thoracic curve, Lenke 1A with thoracic Lordosis -5 degrees.


Decision was made to perform 4 Ponte osteotomies at the apex vertebrae to facilitate the correction of the sagittal plane and to create Kyphosis


The outcome: Thoracic Kyphosis from T5 to T12 20 degrees.

Questions to Consider

  1. Was this appropriate? This type of curve treated for many years with good outcome with the osteotomies, which came to be popular over last 5-8 years.
  2. Would be acceptable to have complications from the osteotomies in this kind of curve?
  3. The added cost for osteotomies fees, would be justifiable with the limited gain in correction?

Please send your feedback to

Here are the comments of some of the committee’s members. They are published to stimulate members to send their input.

  1. Great topic.  Very relevant.  Will be interested in responses
  2. I think that is a good topic.  Can argue on either side of the coin.  But, in the case you presented, probably adds time, risk, expense.  Good food for thought and i think that is the important thing
  3. The flexibility of this curve is not presented, but I would think that excellent correction in both the coronal & sagittal planes can be achieved with standard posterior segmental spinal instrumentation techniques. Harry Shufflebarger's "Posterior Release" which incorporates facetectomy & release of the ligamentum flavum is a simple addition to the procedure to help a bit with the sagittal correction. I consider this a part of my usual construct & correction technique & don't consider it as a separate procedure, nor do I bill for it.
  4. The indiscriminate use of the more complicated Ponte osteotomies with their attendant risks does not seem justified. It does, however, offer another billable part of what should be a simple standard operation. It prolongs the surgery, adds risk of neurologic injury & potentially increased EBL. For this particular case it would seem unjustified and could be seen as unethical as it suggests doing something unnecessary which will benefit the surgeon more than the patient.
  5. I think this case raises good ethical issues.
  6. What if there had been a neurologic complication?
  7. Could correction have been achieved without Ponte's?